Pharmacy fee for service Prior Authorization (PA) Contacts
Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720
Mississippi Medicaid Prescribers
Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.
All providers should register at the following link to submit prior authorization requests:
Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to Change Healthcare Pharmacy PA unit.
Drug Prior Authorization Instructions
| Prior Authorization Packets | Updated |
|---|---|
| Brand Name Multi-Source | 11/1/2018 |
| Early Refill | 11/1/2018 |
| Enteral Nutrition | 11/1/2018 |
| EPSDT – Beneficiaries Under 21 | 11/1/2018 |
| Heterozygous Familial Hypercholesterolemia (HeFH) – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) | 11/1/2018 |
| HeFH with ASCVD – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) | 11/1/2018 |
| Hepatitis C Therapy | 11/1/2018 |
| Homozygous Familial Hypercholesterolemia (HoFH) – REPATHA™ (EVOLOCUMAB) | 11/1/2018 |
| Max Unit Override | 11/1/2018 |
| Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) | 11/1/2018 |
| PDL Exception Request | 11/1/2018 |
| RSV-SYNAGIS® | 11/1/2018 |
| Universal Prior Authorization Form | 11/1/2018 |
Manual Prior Authorization Criteria
Pharmacy Reconsideration Request Form
MedWatch Form
